Contracts A.Y.McDonald & Fire Hdqtrs
DU~~E
~Yk-~
MEMORANDUM
October 9, 2006
TO: Michael C. Van Milligen, City Manager
FROM: Gil D. Spence, Leisure SeNices Manager r
SUBJECT: A.Y. McDonald Park, Change Order
Attached are three copies of a change order for the A.Y. McDonald Park Construction ..
Project. This is a "non-participating" change order, meaning it is not a part of the project
covered by the lOOT Trails Grant we received.
This change order adds $17,793.96 to the contract and includes a number of small
items listed on the change order.
Please sign all three copies and return them to me.
Thanks!
GDS:et
attachments
Form 830240wd
7/00
t;,~ Iowa Department of Transportation
-
Change Order
Non-Substantial:
Non-
Part Part
o IZI
o 0
No. 1 Non-participating
Substantial:
Concurrence Date
Contract
Accounting 10 No.: 24571
County Dubuque
Project No: NRT-NT06(9)--9G-31
Kind of Work: HMA trail and Landscaping
Date Prepared: October 3, 2006
Contractor:
Portzen Construction, Inc. of Dubuque, IA (P0085), Contractor
You are hereby authorized to make the following changes to the contract documents.
A - Descrtption of change to be made or extra work to be done:
8005 - Add sand material for fill underneath concrete slab in front of restroom, including hauling and compaction.
8006 - Add an item for raising the height of an existing fire hydrant.
8007 - Add a pay item for concrete that was delivered to the site but not installed.
8008 - Add a pay item for concrete that was used for mudsills.
8009 - Add an item for removing rock in a planting area and replacing it with topsoil.
8010 - Add an item for installation of erosion stone
B - Reason for change or extra work:
8005 - Overexcavation of topsoil required in front of the restroom facility. Sand used to fill up to required depth instead of base stone.
8006 - Grade raised by Phase I work, and fire hydrant was not adjusted.
8007 - Contractor would like to be reimbursed for the matertla cost of concrete that was not installed, but required due to the restrtctions on
minimim load sizes
8008 - Contractor would like to be reimbursed for concrete mudsills placed as structure footings.
8009 - Rock was iocated in a planting area on the project. Additional excavation and topsoil were required in order to plant the area.
8010- Erosion stone instead of mulch adjacent to Boat ramp
(Continued on~U \ ~
Approved ~ <; <\
(Signature)
Durrant Grouo
Project Architect
l~a~1 (J(p
Receipt is acknowledged of this change or extra work and terms of settiement are hereby agreed to.
By )
City of Dubuque
J 6 - Lf-o t"
Date
!()! 9/rlC
~
DISTRIBUTION: Project Engineer- Forward original to Distrtct.
District - Nonsu_l- Forward orginal and one c:opyto tre Ofti::e of Conslruclion and two oopies back to tre Project Engineer.
~ Substantial - Forward original and two copies to the Office of Construction.
AccDunting ID ND. ~14 I 5 i 7 11 I I
1 234 5 6
C-1 -Settlement for cost of work tD be made as follows:
8005 - 8010 Agreed unit price
Change Order No. 1 - nDn
participatinQ
C-2 - JustificatiDn for cost(s) 8005 cost for hauling material; 8006 cost is in line with cost of materials and labor; 8007
Material cost; 8008- same cost as bid cost of fDoting; 8009-8010 time and material cost
If Credit
D - ITEMS INCLUDED IN CONTRACT Add .CR"
Change Line Item Number Unit Price Quantity Amount
No. .xxx .XXX .XX
-,-
7
7
7
7
7
7
7
TOTAL
IfCredtt,
E - ITEMS NOT INCLUDED IN CONTRACT Add "CR"
Change Item Description Item Number Function Unit Price Quantity Amount
No. Code .XXX .XXX .XX
8005 HAULlNlj," PLACING &GOMPACTING ON-
SITE FILL SAND CY 9.000 65.090 585.81
8006 FIRE HYDRANT EXTENSION (MATERIAL
& LABOR) LS 666.000 1 666.00
8007 CONCRETE DELIVERED BUT NOT
INSTALLED CY 125.000 34.27 4283.75
8008 I CO-NCRETE nJR MUDSILL
CY 450.000 19.25 8662.50
8009 CORE OUT & TOPSOIL (MATERIALS &
LABOR) LS 2170.000 1 2170.00
8010 E~ON STONE
SY 7.350 194.000 1425.90
8
TOTAL $17 793.96
Form 830240wd
7/00
~~ Iowa Department of TransportatIon
-
Change Order
Non-Substantial:
Non-
Part Part
o [ZI
o 0
Concurrence Uate
No. 1 Non-participating
Substantial:
Contract
Accounting ID No.: 24571
County Dubuque
Project No: NRT-NT06(9)--9G-31
Kind of Work: HMA trail and Landscaping
Date Prepared: October 3, 2006
Contractor:
Portzen Construction, Inc. of Dubuque, IA (P0085), Contractor
You are hereby authorized to make the following changes to the contract documents.
A - Description of change to be made or extra work to be done:
8005 - Add sand material for fill underneath concrete slab in front of restroom, including hauling and compaction.
8006 - Add an item for raising the height of an existing fire hydrant.
8007 - Add a pay item for concrete that was delivered to the site but not installed.
8008 - Add a pay item for concrete that was used for mudsills.
8009 - Add an item for removing rock in a planting area and replacing it with topsoil.
8010 - Add an item for installation of erosion stone
B - Reason for change or extra work:
8005 - Overexcavation of topsoil required in front of the restroom facility. Sand used to fill up to required depth instead of base stone.
8006 - Grade raised by Phase I work, and fire hydrant was not adjusted.
8007 - Contractor would like to be reimbursed for the materila cost of concrele that was not inslalled, but required due to the reslrictions on
minimim load sizes
8008 - Conlractor would like 10 be reimbursed for concrete mudsills placed as slructure footings.
8009 - Rock was localed in a planting area on Ihe project. Addilional excavalion and topsoil were required in order 10 plant Ihe area.
8010 - Erosion stone inslead of muich adjacent 10 Boat ramp
(Continued on r~mr d~
Approved ~ C--t
(Signalure)
Durrant Grouo
Project Archilect
1014) (k
Dale
Receipt is acknowledged of Ihis change or extra work and lenms of settlement are hereby agreed 10.
Portzen Construction, Inc.
By )}dAlltlhr
APProved;1/~
ity of Dubuque
)D-Lf-b(/
Date
(~/ 1(<<-
Date
DISTRIBUTION: Project Engineer - Forward original to District.
District - Nonsubslantial- Forward orignal and one copy to !he Office ofConslruclion and two CXlpies bad< to !he Project Engineer.
. Substantial - Forward original and two copies to the Office of Construction.
Accounling 10 No. ~
1 234 5 6
C-1 -Settlement for cost of work to be made as follows:
8005 - 8010 Agreed unit price
Change Order No. 1 - non
participatinR
C-2 - Justification for cost(s) 8005 cost for hauling material; 8006 cost is in line with cost of materials and labor; 8007
Material cost; 8008- same cost as bid cost of footing; 8009-8010 time and material cost
If Credit
D - ITEMS INCLUDED IN CONTRACT Add 'CR"
Change Line Item Number Unit Price Quantity Amount
No. .xxx .xxx .xx
7
7
7
7
7
7
7
TOTAL
IfCredU,
E - ITEMS NOT INCLUDED IN CONTRACT Add 'CR"
Change Item Description Item Number Function Unit Price Quantity Amount
No. Code .xxx .xxx .xx
8005 HAULING, PLACING & COMPACTING ON-
SITE FILL SAND CY 9.000 65.090 585.81
8006 FIRE HYDRANT EXTENSION (MATERIAL
& LABOR) LS 666.000 1 666.00
8007 CONCRETE DELIVERED BUT NOT
INSTALLED CY 125.000 34.27 4283.75
8008 CUNCRETE FOR MUDS ILL
CY 450.000 19.25 8662.50
8009 COREuUT & TOPSOIL (MATERIALS &
LABOR) . LS 2170.000 1 2170.00
8010 ERO:;ION :;TONE
SY 7.350 194.000 1425.90
8
TOTAL $17 793.96
Form 830240wd
7/00
~~ Iowa Department of Transportation
-
Change Order
Non-Substantial:
Non-
Part Part
o [8J
o 0
No. 1 Non-participating
Substantial:
Concurrence Date
Contract
Accounting 10 No.: 24571
County Dubuque
Kind of Work: HMA trail and Landscaping
Project No: NRT-NT06(9)--9G-31
Date Prepared: October 3, 2006
Contractor: Portzen Construction, Inc. of Dubuque, IA (P0085), Contractor
You are hereby authorized to make the following changes to the contract documents.
A - Description of change to be made or extra work to be done:
8005 - Add sand matenal for fill underneath concrete siab in front of restroom, including hauling and compaction.
8006 - Add an item for raising the height of an existing fire hydrant.
8007 - Add a pay item for concrete that was delivered to the site but not installed.
8008 - Add a pay item for concrete that was used for mudsills.
8009 - Add an item for removing rock in a planting area and replacing it with topsoil.
8010 - Add an item for installation of erosion stone
B - Reason for change or extra work:
8005 - Overexcavation of topsoil required in front of the restroom facility. Sand used to fill up to required depth instead of base stone.
8006 - Grade raised by Phase I work, and fire hydrant was not adjusted.
8007 - Contractor would like to be reimbursed for the matenla cost of concrete that was not installed, but required due to the restrictions on
minimim load sizes
8008 - Contractor would like to be reimbursed for concrete mudsills placed as structure footings.
8009 - Rock was located in a planting area on the project. Additional excavation and topsoil were required in order to plant the area.
8010 - Erosion stone instead of mulch adjacent to Boat ramp
(Continued on re~e) l)\~
Approved ~ q
(Signature) .
Durrant Grouo
Project Architect
~
Receipt is acknowledged of this change or extra work and terms of settlement are hereby agreed to.
By
/6 - 4-C0
Date
~~I ~M/
~
Approved
DISTRIBUTION: Project Engineer - Forward original to District.
District - Nonsubslanlial- FOIWBrd ..gina and one copy to the 0IIice of ConstrucIion and two copies bad< to the Project Engineer.
~ Substantial - Forward original and two copies to the Office of Construction.
Accounting 10 No. ~
1 234 5 6
C-1 -Settlement for cost of work to be made as follows:
BOOS - B01 0 Agreed unit price
Change Order No. 1 - non
participating
C-2 - Justification for cost(s) BOOS cost for hauling material; B006 cost is in line with cost of materials and labor; 8007
Material cost; BOOB- same cost as bid cost of footing; 8009-8010 time and material cost
If Credit
D - ITEMS INCLUDED IN CONTRACT Add 'CR"
Change Line Item Number Unit Price Quantity Amount
No. .XXX .XXX .XX
7
7
7
7
7
7
7
TOTAL
ItCredit,
E - ITEMS NOT INCLUDED IN CONTRACT Add 'CR"
Change Item Description Item Number Function Unit Price Quantity Amount
No. Code .XXX .XXX .XX
8005 HAULING, PLACING & c;OMPAc;TING ON-
SITE FILL SAND . CY 9. 000 65.090 585.81
8006 FIRE HYDRANT EXTENSION (MATERIAL
& LABOR) LS 666.000 1 666.00
8007 CONCRETE DELIVERED BUT NOT
INSTALLED CY 125.000 34.27 4283.75
8008 CONCRETE FOR MUDS ILL
CY 450.000 19.25 8662.50
8009 CO.RE OUT & TOPSOIL (MATERIALS &
. LABOR) LS 2170.000 1 2170.00
8010 EROSION STONE
SY 7.350 194.000 1425.90
8
TOTAL $17793.96
D~~~E
~c/N.-~
MEMORANDUM
October 10, 2006
FROM:
Michael C. Van Milligen, City ManaTiY)
Gus Psihoyos, City Engineer JJ0
Fire Headquarters - Sidewalk Replacement
TO:
SUBJECT:
Enclosed is the improvement contract between the City of Dubuque and Skyline
Construction for the replacement of sidewalk at the Fire Headquarters on 9th Street.
I have reviewed the documentation and found it to be in order.
Ken TeKippe has approved the Certificate of Liability Insurance to ensure its
compliance with the City's insurance requirements.
I would request that you execute the contract and return it to my office.
~c: Steven Sampson Brown, Project Manager
~~(ncs
D~~~E
~c/4.-~
MEMORANDUM
September 25, 2006
TO: Steve Sampson Brown, Civil Engineer
FROM: Kelly Ambrosy, Engineering Assistant K~
SUBJECT: Short Contract with Skyline Construction
Attached please find executed sidewalk replacement at Fire Headquarters.
The sales tax form is also attached.
Ken TeKippe, Finance Director, is in the process of working with Skyline's insurance
agent for the remaining insurance forms.
Please please me know if there are any problems on this contract.
Thanks.
D~~~E
~ck~
City of Dubuque
Engineering
50. W. 13'h Street
Dubuque, IA 52001
(563) 589-4270
(563) 589-4205 FAX
CITY OF DUBUQUE, IOWA
SHORT FORM
IMPROVEMENT CONTRACT
THIS IMPROVEMENT CONTRACT (the Contract), made in triplicate, dated for reference
purposes between the City of Dubuque, Iowa, by its City Manager, through authority conferred
upon the City Manager by its City Council (City) and Skyline Construction of the City of Dubuque,
Iowa.
For and in consideration of the mutual covenants herein contained, the parties hereto agree
as follows:
CONTRACTOR AGREES:
1. To furnish all material and equipment and to perform all labor necessary for (the
Project): Fire Headquarters Sidewalk Replacement - approximately 1,593 square feet at 6"
depth
The work described above shall be completed at the following location(s): Fire
Headquarters - 9th Street
The Project shall be constructed to the existing grades and to any revised grades as described
in this Project contract; in strict accordance with the requirements of the laws of the State of
Iowa and ordinances of the City of Dubuque relating to public works, and in accordance with the
Contract Documents which provisions and documents are each and all hereby referred to and
made a part of this Contract just as much as if the detailed statements thereof were repeated
herein.
Page 1 of 4
2. Contract Documents shall mean and include the following: All ordinances and resolutions
heretofore adopted by the City Council having to do with the Project; the Contractor's Proposal;
and the conditions described in the Contract, including any Special Conditions, Plans and
Specifications and General Requirements as adopted by the City Council for the Project.
3. All materials used by the Contractor in the Project shall be the best of their several kinds and
shall be put in place to the satisfaction of the City Manager.
4. The Contractor shall remove any materials rejected by the City Manager as defective or
improper, or any of said work condemned as unsuitable or defective, and the same shall be
replaced or done anew to the satisfaction of the City Manager at the cost and expense of the
Contractor.
5. Five percent (5%) of the Contract price may be retained by the City for a period of thirty (30)
days after final completion and acceptance of the Project by the City Manager to pay any claim
that may be filed within said time for labor and materials done and furnished in connection with
the performance of this Contract and for a longer period if such claims are not adjusted within
that time, as provided in Iowa Code Chapter 573. The City shall also retain additional sums to
protect itself against any claim that has been filed against it for damages to persons or property
arising through the prosecution of the work and such sums shall be held by the City until such
claims have been settled, adjudicated or otherwise disposed of.
6. The Contractor has read and understands the City of Dubuque Standard Specifications
including General Requirements and has examined and understands the project description
described in Section 1 and any attached Special Conditions herein referred to and agrees not to
plead misunderstanding or deception because of estimates of quantity, character, location or
other conditions surrounding the same.
7. The Contractor shall guarantee for a period two years and make good any other defect in any
part of the Project due to improper construction or material performance notwithstanding the
fact that said Project may have been accepted and fully paid for by the City. The guarantee
shall commence on the date that the City pays full compensation for the complete performance
of this contract.
8. The Contractor shall fullv complete the Project under this Contract on or before October 31,
2006.
9. To the fullest extent permitted by law, the Contractor shall indemnify and hold harmless the City
from and against all claims, damages, losses and expenses, including but not limited to
attorneys' fees, arising out of or resulting from performance of the Contract, provided that such
claim, damages, loss or expense is attributable to bodily injury, sickness, disease or death, or
injury to or destruction of property (other than the Project itself) including loss of use resulting
there from, but only to the extent caused in whole or in part by negligent acts or omissions of
the Contractor, the Contractor's subcontractor, or anyone directly or indirectly employed by the
Contractor or the Contractor's subcontractor or anyone for whose acts the Contractor or the
Contractor's subcontractor may be liable, regardless of whether or not such claim, damage,
loss or expense is caused in part by a party indemnified hereunder.
Page 2 of 4
10. Unless otherwise provided in the Contract Documents, the Contractor shall provide evidence of
insurance which meets the requirements of the City's Insurance Schedule for General
Contractors or Artisan Contractors.
THE CITY AGREES:
Upon the completion of the Contract, and the acceptance of the Project by the City Council,
the City agrees to pay the Contractor as full compensation for the complete performance of this
Contract, the amount determined for the total number of units completed at the unit prices stated in
the Contractor's Proposal and less any liquidated damages provided for in the Contract
Documents. The number of units stated in the contract, special conditions and contractors
proposal is approximate only and the final payment shall be made by the work covered by the
Contract.
CONTRACT ESTIMATED AMOUNT $ 11,150.00
THE MAXIMUM CONTRACT AMOUNT SHALL BE LIMITED TO AN INCREASE OF 5% OF THE ABOVE LISTED
ESTIMATED AMOUNT.
By:
PRINCIPAL:
Id/Jj/(J/,.
Date (
By:
'5/{ y I : --<'~ G..... ') -k-vc--\-.. '"'"'
Contractor
I1J) ~ af-
Signatuf .
fY}~\( t, '11..- J~"<-,
'Printed Name
9/'-P-/(J{,
Date
{J,-<<-":>:J......~\-
Title
ACKNOWLEDGEMENT OF ATTACHED
SPECIAL CONDITIONS:
By:
J(j (f) Signature Date
Printed Name
Title
Page 3 of 4
PROJECT INFORMATION REQUIREMENTS FOR
STATE OF IOWA SALES TAX EXEMPTION CERTIFICATES
FOR CONTRACTORS & SUBCONTRACTORS
Submitting Department: _ _Engineering Department
Please complete this form in its entirety and submit along with the executed Construction Contracts, Bonds
and Certificate of Insurance. Upon receipt, the City Finance Department will work with the Iowa
Department of Revenue to issue Sales Tax Exemption Certificates to the approved contractor(s) to allow
for the purchase or inventory withdrawal of materials for the specified Construction Project free from State
of Iowa Sales Tax.
Construction Project Name:
Fire Headquarters Sidewalk Replacement
Project Description:
Sidewalk repairs at Fire Headquarters
Start Date (Bid let date):
~ 9-22-06
I Completion Date:
110-31-06
I. General Prime Contractor:
Contact Name:
Complete Address:
(Include PO Box and Street Information)
City, State, Zip Code
Telephone Number:
Federal 1.0. Number:
(or Include Social Security Number)
Work Type to be Completed:
Skyline Storage & Trucking, Inc.
Mark Arthoeffer
13582 Skyline Road
Zwingle, IA 52079
(563) 599-2375
42-1512376
Replace concrete sidewalks
2. Subcontractor:
Complete Address:
(Include PO Box and Street Infonnation)
City, State, Zip Code
Telephone Number:
Federal 1.0. Number:
(or Include Social Security Number)
Work Type to be Completed:
Aur 18 06 02:40p
Loveless Tri
State Ins
5635849237
p.2
ACORD,.
CERTIFICATE OF LIABILITY INSURANCE
I
DATE (MMIOOIYY)
PRODUCER
2 06
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
I Tri-State Insurance. Group, LLC
3400 Asbury Road, Suite 10
Dubuque, Iowa 52002
~8~
INSURED Skyline storage & Trucki.ng Inc.
INSURERS AFFORDING COVERAGE
13626 Skyline Road
Zwingle, Ia 52079
INSURER A Ac1.l i ty In.s....u.r.ance Co-.mp.-any:
INSURER B:
INSURER c:
INSURER 0:
INSURER E-
COVERAGES
THE POL1CIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO wHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~f~ TYPE OF INSURANCE POUCY NUMBER ~~~~YM'ij%~mVE P8k+iY MJ~ON LIMITS
GENERAL LlABIUTY
~. COMMERCIAL GENERAL LIABILITY
CLAIMS MADE W OCCUR
A F70705
~'lAGGREGATE LIMiT APPLIES PER: I
POLlCY ~~t'T LOC
AUTOMOBILE LIABILITY
Q ANY AUTO
H ALL OWNED AUTOS
S SCHEDULEO AUTOS
A HIRED AuTOS F7 0 7 0 5
NON-OWNED AUTOS
F70705
EACH OCCURRENCE . 1.000 000_
FIRE DAMAGE (Anyone fire) --iliLQ
MEO EX? (Anyone person) <=:.:l. 1,lded_
102-02-06 02-02-07 PERSONAL s. ADV INJURY . QQ9_
GENERAl AGGREGATE S ,jLQ 0 000.
pRODUCTS - COMP/OP AGG , 00.000
COMBINED SINGLE LIMIT '1,000,000
(Eaacc:ident)
BOOIL Y INJURY $
(Per parson)
02-0.2-06 02-02-07 BODlL Y INJURY ,
(Peraceidant)
PROPERTY DAMAGE $
(Peraccidenl)
AUTO ONLY - EA ACC1DENT $
OTHER THAN EAACC ,
AUTO ONLY: AGG S
EACH OCCURRENCE , 000.000
AGGREGATE !4-QOJL
02-02-06 02-02-07
GARAGE UABILlTY
ANY AUTO
EXCESS LIABIUTY
OCCUR 0 CLAIMS MACE
A DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION AND
EMPLOYERS' UAmUTY F70705
A
.OntER F70705
A In:l.and MaJ:ine
02-02-06 02-02-07
10,000
02-02-06 02-02-07 Cargo Coverage
DESCRIPTION OF OPERATlONSlLOCATIONSNEHICLESJEXCLUSJONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
city of Dubuque 2006 Sidewalk Inspection Project #1- Except for non payment of
premium The City ofDubuque, including a:l.l its elected officials, all its
employees and volunteers,all it's boards, commissions and or authorities, and
their boaJ:d members,employees, and volunteers are additional insureds on the
geneJ:al liab~lity policy for our insured Skyline Storage & Trucking Inc.
CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATlON
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPlRAT
DATE THEREOF, niE ISSUING INSURER WILL ~O MAIL ..3.0....- DAYS WAlTTE
NonCE TO THE CERTIACATE HOLDER NAMED TO THE LEFT, aUT FAILURE TO 00 SO SHA!.
IMPose NO OBLIGATION OR UABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS 0
Fax 589-4205
@ACORDCORPORATION 1981
City of Dubuque/Engineering Dept
City Hall
Dubuque, Iowa 52001
ACORD 25-S (7/97)
,.;Aug, i8 08 02:39p
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Loveless Tri
State Ins 5835849237
p. 1
LOVELESS
/,,/ TRI-STATE
~ INSURANCE GROUP, LLC
3400 Asbury Road, Suite 10 I Dubuque, Iowa 52002 I PHONE (563) 584-9235 I TOLL fREE (877) 584-9235 I fAX (563) 584-9237
Fax
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From: Mike Loveless
Phone:
Pages: -;;<
Date: 'i{ - / $--{] Co
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3400 Asbury Road, 5uite 10 I Dubuque, Iowa 52002 I PHONE 1563) 584-9235 I TOLL FREE (877) 584-9235 I FAX 15631584-9237
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Loveless lri
State Ins
5635849237
p.2
~ODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER_ THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW_
INSURERS AFFORDING COVERAGE
ACORD,. CERTIFICATE OF LIABILITY INSURANCE
rri-State Insurance Group, LLC
3400 Asbury Road, Suite 10
Dubuque, Iowa 52002
563-584-9235
SURED Skyline Storage & Trucking Inc.
13626 Skyline Road
Zwingle, Ia 52079
INSURER A:
INSURER B:
INSURER c:
INSURER 0:
INSURER E:
surance Comp...any:
OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. eXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN rv1AY HAVE BEEN REDUCED BY PAID CLAIMS.
'R TYPE OF INSURANCE POUCY NUMBER - j- p01.WrlFFECT}~E P&k{i';r?:~~J}9N LIMITS
CR DATE MMfDDfYY
~NERAl LIAI3!L.ITY I EACH OCCURRENCE · 1_000.00rl
v COMMERCIAL GENERAL LIABILITY I FIRE DAAtAGE (Anyone fire) . 5_0 nnn
I CLAIMS MADE GJ OCCUR: MED EXP (Any ane person) . I_tl_C' .....-...
A. ~ F70705 02-02-06 02-02-07 PERSONAL & ADV INJURY . 1 """ """
- GENERAL AGGREGATE $ 1 _ nllJl """
-:;i'L AGGREGATE LIMIT APPLIES PER; PRODUCTS - CQMP/OP AGO :, 1 '-,,-,,-,..-- """
r--. PRO- n-
"V POLICY JECT LOC
AUTOMOBILE LIABIUTY ,
COMBINED SINGLE LIMIT
~I ANY AUTO (Eaaccldllnl) $1,000,000
~' ALL OWNED AUTOS BOOIL Y INJURY .
"'- SCHEDULED AUTOS (PerpersOll)
A. -X HIRED AUTOS , F70705 02-02-06 02-02-07 BODilY INJURY
-X. , (Per accidenlJ $
NON-OWNED AUTOS
- ------------ . PROPERTY DAMAGE .
(Perac:Cidenl)
==1:0E L1AO",TY AUTO ONLY- EA ACCIDENT S
ANY AUTO OTHER THAN EAACC ,
I i AUTO ONLY: AGG .
,
EXCESS lIABILITY EACH OCCURRENCE ' '1 _ 000. OQJL___
~ OCCUR II CLAIMS MADE AGGREGATE · 1_J1ll9_~0~
F70705 02-02-06 02-02-07 .
A. R DEDUCTIBLE .
RETENTION S S
WORKERS COMPENSATION AND X I iii\\ilf.J:l. I I al~-
EMPLOYERS' LIABILITY F7070S 02-02-06 .02-02-07 E.L. EACH ACCIDENT S 1nn _OQQ
A. E.L. DISEASE. EA EMPLOYE . 1"" - ,,";,,-
E.L. DISEASE - POLICY LIMIT I $ 5"n-nn"
I OTHER F70705 02-02-D6 02-02-07 Cargo Coverage 10,000
"IInland Marine ,
i
:SCRIPTION OF OPERA110NS/LOCATIONSNEHICLESlEXCl.USIONS ADDED BY ENDORSEMENTfSPECIAl. PROVISIONS
E'roject:2006 City of Dubuque Sidewalk Inspection program or any other curbing
~r sidewalk work in the public right of way for the city of Dubuque. The city
~f Dubuque ~s an additional insured per attached IL7063. (This includes ongo~ng
~nd completed operations;primary/noncontributory;per project aggregate
:G2503;govermental immunities;waiver of subrogation on workers compensation.
ERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAll...3..0.- DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHAl.L
City of Dubuque/Engineering Dept
City Hall
Dubuque, Iowa 52001
IMPOSE NO OBL.IGATION OR lIABILITY OF ANY KINO UPON THE INSURER, ITS AGENTS OR
Fax 589-4205
CORD 25-5 (7197)
Sep 29 06 03:15p
Loveless Tri
ADDITIONAL INSURED CITY OF DUBUQUE, IOWA
This endorsement modifies insurance provided under
the following:
BUSINESS AUTO COVERAGE FORM
COMMERCIAL GENERAL LIABILITY COVERAGE PART
BIS-PAK BUSINESS LIABILITY AND MEDICAL
EXPENSES COVERAGE FORM
1. The City of Dubuque, Iowa, including all its
elected and appointed officials, all its employ-
ees and volunteers, all its boards. commissions
and/or authorities and their board members,
employees and volunteers, are included as ad-
ditional insureds with respect to all work and
services perfonmed for them. This coverage
shall be primary to the additional insureds and
not contributing with any other insurance or
similar protection available to the additional in-
sureds, whether other available coverage be
primary, contributing or excess.
2. The following applies when the City of Du-
buque, Iowa is named as an additional insured:
a. We expressly agree and state that the pur-
chase of this policy and the naming of the
City of Dubuque, Iowa as an additional in-
sured does not waive any of the defenses
of governmental immunity available to the
City of Dubuque, Iowa under the Code of
Iowa Section 670.4 as it now exists and as
it may be amended from time to time.
b. We further agree that this policy of insur-
ance shall cover only those claims not sub-
ject to the defense of governmenlal immu-
nity under the Code of Iowa Section 670.4
as it now exists and as it may be amended
State Ins
5635849237
p.3
IL-7063(7 -02)
from time to time. Those claims not subject
to the Code of Iowa Section 670.4 shall be
covered by the terms and conditions of this
policy.
c. The City of Dubuque, Iowa shall be respon-
sible for asserting any defense of govern-
mental immunity I and may do so at any
time and shall do so upon timely written
request by us.
d. We shall not deny coverage under this poli-
cy and we shall not deny any of the rights
and benefits accruing to the City of Du-
buque, Iowa under this policy for reasons of
governmental immunity unless and until a
court of competent jurisdiction has ruled in
favor of the defense(s) of governmental im-
munity asserted by the City of Dubuque,
Iowa.
e. We and the City of Dubuque, Iowa agree
that the above preservation of governmental
immunities shall not otherwise change or
alter the coverage available under the poli-
cy.
3. We will give thirty (30) days advance written
notice of cancellation, nonrenewal, reduction in
coverage or limits and/or material change by
endorsement and ten (10) days written notice
for nonpayment of premium to: City of Dubuque
and Dubuque County, Cily Hall, 13th and Cen-
tral, Dubuque, IA 52001. This endorsement su-
persedes the standard cancellation statement
on the Certificate of Insurance to which this
endorsement is attached.
Sep 29 06 03: 16p
Loveless Tri
State Ins
5635849237
p.4
NOTICE OF CANCELLATION ENDORSEMENT
IL-7002(10.90)
All Coverage Parts included in this policy are subject
to the following condition:
If we cancel this policy, for any reason other than
nonpayment of premium, we will mail advance notice
to the person(s) or organization(s) as shown in the
Schedule.
SCHEDULE
Person or Organization
(Namlll and Address)
Advance Notice
(Days)
CI1Y OF DUBUQUE IA
ENGINEERING OEPT CI1Y HALL
13TH & CENTRAL
DUBUQUE IA 52001
30